Every finding on record at Rainbow Hospice LLC

Upon patient record review 1 of 15 (Patient #4) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #4: There was no spiritual care component completed as a part of the comprehensive assessment.

Upon patient record review, 4 of 15 (Patients #1, 2, 3, 8) did not have evidence in the record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: The medication profile did not have complete oxygen entry. The profile included, "Oxygen 2.5LT gas inhalation". This entry does not specify liters per minute. It does not include if oxygen is to be delivered via NC or Mask. This does not include whether oxygen is continuous or prn. Patient #2: The patient is on prn Oxygen. Oxygen is not on the medication profile. Patient #3: The patient had admission order for Oxygen at 2-4 Liters per nasal cannula though Oxygen is not included on the medication profile. Patient #8: Patient had an order for Acetaminophen 650 mg. The route is listed as rectal, though it does not specify whether suppository or tablet.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 5 of 15 (Patient #3, 4, 5, 9, 10) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #3: The patient was admitted on 6/07/22. A wound was measured. There was no follow up visit from admission until 6/15/202022. On 6/15/22, Ativan was ordered for the patient. There was no follow up phone call or visit to the patient for 7 days. On 6/22/22, Ativan orders were changed from prn to scheduled, as symptoms had not improved. No follow up phone call or visit for 7 days. On 7/18/22, call from family stating that patient having abdominal pain. New medication orders received. No nursing assessment made. On 7/20/22 at 850am, call from family, patient "refusing meds and food, c/o stomach pain, patient screaming all the time". Mylanta ordered over the phone, and no visit made. Phone call received at 738pm that patient was weak and barely opening eyes. Nurse dispatched and arrived at 7:50 pm. Patient was deceased. Patient #4: Patient admitted 7/30/22. No follow up assessment completed for 4 days despite daily calls from family regarding various needs. On 8/12/22 there was a call from family regarding swelling on cheek. They were also requesting mouth swabs. Augmentin ordered for possible cellulitis with no assessment, no visit made until next day. On 8/13/22, visit made and patient noted to have "drooped L lip". No follow up call or visit made for 6 days. On 9/4/22 a call received from family stating patient has had cough for "few days". Also stating SPO2 was 90%. Oxygen started and Antibiotic ordered though no visit or nursing assessment done. No further phone call or follow up visit for 6 days. Patient #5: Patient admitted 10/27/22 with Pancreatic Cancer. Aide visit was done 10/30/22. Aide called RN to report pt. pain 4/10. Order received for tramadol prn. No follow up call or visit made for 5 days. Patient #9: On 02/05/23 a visit made and patient with new complaints of insomnia. Trazadone ordered prn. No follow up call or visit for 7 days. On 02/12/23, visit made and patient still experiencing insomnia. Trazadone increased. No follow up phone call or visit for 5 days. On 03/05/23, Antibiotics ordered for Cellulitis of peri area. No follow up visit or phone call until the son called on 03/08/23 to state patient had developed a "rash all over" after starting Keflex. No nursing visit to assess allergic reaction, no follow up phone call or visit for 4 more days. On 03/19/23 nursing visit made and patient complaints of itching. New medication ordered for itching. No follow up phone call or visit made for 7 days. Patient #10: On 03/17/23, ALF staff called stating patient had no output since prior day and was experiencing dyspnea. No visit made. On 04/24/23, facility called stated that patient had foul smelling urine. No nursing assessment or visit completed. No follow up phone call or visit for 2 days.

Upon patient record review, 10 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 10, 11) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #1: This patient was admitted to hospice with Chronic Respiratory Failure and COPD. Related conditions included Type 2 diabetes. The plan of care did not include interventions or goals related to the primary diagnosis. Type 2 Diabetes is listed as a related diagnosis and metformin is a covered medication. There are no interventions or goals regarding diabetes. The patient uses nebulized medications, though there is no interventions for the nebulizer including education provided on its use. Patient #2: The patient was admitted with Chronic diastolic heart failure. The related diagnoses included COPD. The plan of care did not include interventions or goals related to his primary or related diagnoses. Admission orders state that the physician ordered a suction machine and a nebulizer. These are not included in the interventions or goals on the plan of care. Patient #3: The patient was admitted with Cerebral infarct. The plan of care is missing interventions or goals related to neuro for this primary diagnosis. The patient was admitted with 6 different wounds. The plan of care does include skin breakdown or interventions and goals for 5 of the wounds. Patient #4: The patient was admitted with Contusion and laceration of "cereb" with LOC change. The plan of care is missing interventions and goals related to pain, respiratory/dyspnea. There is a suction machine ordered on admission orders but it is not included in the plan of care. In addition, the patient has a peg tube. The patient has orders to receive isosource 1.5 via peg tube. Tube feeding was not included in the plan of care. Patient #5: The patient was admitted with a primary diagnosis of Pancreatic cancer. The plan of care does not have interventions or goals related to primary diagnosis of pancreatic cancer. Patient #6: The patient was admitted with Acute Respiratory failure. The plan of care does not include interventions or goals related to respiratory as primary diagnosis. Patient #7: The patient was admitted with primary diagnosis of HIV., and the clinical record reflected the patient was being provided with narcotic pain medication. The plan of care does not include problem, interventions or goals for Pain. There is a suction machine ordered on admission orders but it is not included in the plan of care and there is no interventions. Patient #8: The patient was admitted with primary diagnosis of Lung cancer with related diagnoses of secondary cancer to brain and bone. The plan of care did not include a problem statement with interventions and goals for cancer, or respiratory. There is a suction machine ordered on admission orders but it is not included in the plan of care and there is no interventions. Patient #10: The patient was admitted with intracranial hemorrhage and related conditions included COPD. The plan of care did include a problem statement with interventions and goals for dyspnea. There is a suction machine ordered on admission orders but it is not included in the plan of care and there is no interventions. Patient #11: The patient was admitted with Alzheimer's disease. The plan of care did not contain a problem statement with interventions and goals related to primary diagnosis. The patient had a Geri chair, but no interventions or goals for fall safety including use of Geri chair. There is a suction machine ordered on admission orders but it is not included in the plan of care and there is no interventions.

Upon patient record review, 4 of 15 (Patients #5, 6, 8, 9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. The plan of care frequencies ranges cannot include a 0. Patient #5: The plan of care indicated MSW frequencies of 0-1 per month. The plan of care indicated frequencies for the SC of 0-1 visits per month. The plan of care frequency ranges cannot include a 0. Patient #6: The plan of care indicated MSW frequencies of 0-1 per month. The plan of care frequency ranges cannot include a 0. Patient #8: The plan of care indicated MSW frequencies of 0-1 per month. The plan of care frequency ranges cannot include a 0. Patient #9: The plan of care indicated MSW frequencies of 0-2 per month. The plan of care indicated SC frequency of 0-1 per month. The plan of care frequency ranges cannot include a 0.

Upon patient record review, 8 of 15 (Patients #1, 2, 4, 6, 7, 8, 10, 11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #1: The plan of care does not include oxygen. Patient #2: The plan of care does not include oxygen. In addition, there are no ordered nebulized medications. Patient #4: The plan of care does not include oxygen. In addition, there are no orders for dressing changes on the plan of care for wound/s. Patient #6: The plan of care does not include oxygen. Patient #7: The plan of care does not include oxygen which was ordered at start of care. Patient #8: The plan of care does not include oxygen. Patient #9: The patient was admitted with 6 different wounds. It does not list the detailed wound orders for 5 of the wounds. Patient #10: The plan of care does not include oxygen. There are incomplete wound care orders for new skin tears on 03/18/23 (missing cleansing of skin tear, indication for prn change, and who is to change dressing), 03/31/23 (Missing frequency of dressing change and who is to change), and 05/06/23 (missing who is to change dressing and how often). Patient #11: The plan of care does not include oxygen.

Upon patient record review, 11 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including supply needs. Patient #1: There are no supplies listed on patient plan of care including oxygen/respiratory supplies. Patient #2: There are no supplies listed on patient plan of care including oxygen/respiratory supplies. Patient #3: There are no supplies listed on patient plan of care including oxygen/respiratory supplies, wound care supplies. Patient #4: There are no supplies listed on patient plan of care including oxygen/respiratory supplies, wound care supplies for peg tube site care, enteral feed supplies, incontinence supplies, mouthcare supplies. Patient #5: There are no supplies listed on patient plan of care including wound care supplies Patient #6: There are no supplies listed on the patient plan of care including oxygen/respiratory supplies, thick it, supplements including ensure. Patient #7: There are no supplies listed on the plan of care, including oxygen/respiratory supplies Patient #8: There are no supplies listed on plan of care including oxygen/respiratory supplies Patient #9: There are no supplies listed on plan of care including oxygen/respiratory supplies, anti bacterial soap (requested on patient triage phone call on 2/24/23). Patient #10: There are no supplies listed on plan of care including oxygen/respiratory supplies, incontinent supplies, wound care supplies Patient #11: there are no supplies listed on plan of care including oxygen/respiratory supplies.

Upon patient record review, 3 of 15 (Patients #8, 9, 10) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #8: The patient received continuous care beginning 12/21/22. Though the plan of care does not include a plan of care update to add change in level of care or continuous care to that plan with interventions and goals. Patient #9: The patient was seen and treatment was initiated for insomnia and evening agitation on 02/05/22. There was no plan of care update to include new problem statement as well as interventions and goals for insomnia or agitation. The patient was seen and treatment was initiated for cellulitis on peri area. No update of the plan of care was made to include infection with interventions and goals. The patient developed itching from allergic reaction to antibiotic. Medication was initiated for itching, though interventions and goals for itching were not added to the plan of care. Patient #10: The patient was diagnosed with UTI and prescribed antibiotic on 04/24/23. There was no update to the plan of care to include interventions and goals related to infection.

Upon patient record review, 2 of 15 (Patients #3, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #3: The plan of care stated that wounds would be measured weekly. The patient record contained only one assessment with wound measurements on one wound at start of care. No further wound assessments with measurements are present in the patient record. Patient #4: The plan of care does not include orders to change peg site dressing, though peg site dressing was changed on 08/13/22.

Upon observation, there was no evidence the hospice is in compliance with accepted professional standards and principles for all core services which includes nursing services, medical social services and counseling services. No evidence all IDG members were responsible for the plan of care for each hospice patient and there is a lack of consistency for the plan of care development and adhering to the plan of care.

Upon observation, there was no evidence the hospice provides nursing care and services by or under the supervision of a Registered Nurse. No evidence governing body along with the nursing staff were being responsible for the plan of care for each hospice patient and there is a lack of consistency for the plan of care development and adhering to the plan of care.

Upon personnel record review, 1 of 11 (Personnel #1) did not have evidence that all bereavement services are provided by a qualified counselor in accordance with applicable laws and regulations, professional practice standards, the hospice's policies and procedures and/or job descriptions which includes experience or education in grief or loss counseling. Personnel #1: Bereavement job description for bereavement coordinator required the following minimal requirements: "1. A qualified professional with experience or education in grief or loss counseling. (Bachelor's degree or equivalent theological degree from college or university. Experience with families/caregivers and patients through death/dying issues - OR- Master's degree in Social work with qualifications of experienced clinical grief counseling). 2. Two years related experience preferred. 3. Experience with counseling individuals and/or groups. 4. A qualified professional with experience or education in grief or loss counseling. The administrator is a registered nurse with a bachelors degree. He reports that he has been providing the bereavement services for the past 1-2 months."

Upon patient record review 1 of 15 (Patient #1) did not have documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1: Aide ordered 3-5 visits per week. Frequency was not met on week 1 of care.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. No evidence the governing body was being responsible for the plan of care for each hospice patient and there is a lack of consistency for the plan of care development and adhering to the plan of care.

Upon patient client record review, 1 of 15 (Patient #3) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #3: This patient was admitted with a primary diagnosis of Cerebral infarct and related diagnoses of: Protein calorie malnutrition, pressure ulcer of left hip stage 4, deep tissue injury to left hip, stage 2 pressure ulcer of left buttock, stage 3 pressure ulcer to right heel, stage 3 "other", stage 4 "other. During the comprehensive assessment, the nurse did not capture all objective wound data as evidenced by, RN listed 8 wounds, though assessed/collected data for only the stage 4 pressure ulcer of the left hip. The remaining wounds did not have an assessment or collected data including measurements.

Upon review of clinical records, 15 of 15 (Patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15) did not have documented evidence that the written policies and procedures for managing controlled drugs was provided and discussed. The EMR section of Initial Nursing Assessment contained an intervention of, "Instruction on Disposal of Hazardous Waste"; rather than "instruction on safe disposal of controlled drugs."

Upon patient record review, 2 of 9 records (Patients #6,#8) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications. Patient 6: The medication list contained Miralax with no evidence of instructions for a diluent. Corrected on site. Patient 8: The medication list contained Miralax with no evidence of instructions for a diluent. The medical record contained nursing documentation 7-2-21 identifying patient use of oxygen. There was no evidence of oxygen listed on the medication list.

Upon patient record review, 1 of 9 records (Patient #1) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component. Patient 1: The medical record contained an initial bereavement assessment dated 9-10-21. Start of care was 5-29-21.

Upon patient record review, 7 of 9 records (Patients #1,#2,#3,#6,#7,#8,#9) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patients 1,2,3,7,8: There was no evidence of problems, goals, and interventions related to spiritual care services included on the plan of care. Patient 6: The medical record contained documentation identifying patient primary hospice diagnosis of pulmonary fibrosis and nursing documentation upon admission identifying use of oxygen. There was no evidence of problems, goals, and interventions related to respiratory included on the plan of care. Patient 7: The medical record contained nursing documentation upon admission identifying patient issues with difficulty swallowing and patient not eating and drinking. There was no evidence of problems, goals, and interventions related to nutrition or hydration included on the plan of care. Patient 9: The medical record contained nursing documentation upon admission identifying patient issues with respiratory issues causing oxygen administration and nebulizer treatments. There was no evidence of problems, goals, and interventions related respiratory included on the plan of care.

Upon client record review, 1 of 9 records (Patient #8) did not have evidence that the IDG in collaboration with the attending physician reviewed, revised and documents the individualized plan as frequently as the patient's condition requires but no less frequently then every 15 calendar days. Patient 8: The medical record contained IDG dates of 5-31-21 and 6-28-21 with 28 days between the dates.

Upon client record review, 1 of 9 records (Patients #8) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 8: The medical record contained ordered volunteer frequency 1-2 times weekly. There was no evidence of volunteer visits documented in the medical record.

Upon patient record review, 4 of 5 applicable records (Patients #1,#2,#3,#8) did not have evidence in the patient record that hospice aide assignments and duties include the tasks to be provided and the frequency of those tasks. Patient 1: There was no evidence of an active aide care plan. There were two aide visit notes on 9/28/21 and 10/5/21 with no documentation of any tasks completed. Patient 2: The aide care plan contained task for oral hygiene with a frequency as needed. Corrected on site. Patient 3: The aide care plan contained task for light housekeeping with a frequency as requested by facility. Corrected on site. Patient 8: The aide care plan contained tasks for both bed bath if refuse shower and shower unless refused. Tasks also contained assist with ambulation, transfer, and incontinent care with frequencies as needed.

Upon patient record review, 8 of 9 records (Patients #1,#2,#3,#5,#6,#7,#8,#9) did not have evidence that the medical director provided written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. Patients 1,2,3,5,6,7,8,9: There was no evidence of written certification that included narrative of determining factors for eligibility.

Upon patient record review, 2 of 2 applicable records (Patients #1,#6) did not have evidence of a written certification including narrative for the recertification period. Patient 1 and 6: There was no evidence of a written certification of illness upon recertification.

Upon patient client record review, 1 of 9 records (Patient #7) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Patient 7: The medical record contained chaplain documentation with data entry error that visit was completed 3-25-21. Visit occurred 2-25-21.